Welcome. This blog is your opportunity to ask questions of the physicians of Yale School of Medicine and Yale Cancer Center. While it is no substitute for a professional diagnosis, and people must always consult with their personal physicians to make decisions about their course of treatment, the information provided here may help you make more informed choices. Answers to questions will be posted on this site, not sent via email. Please understand that we cannot answer every question submitted. Also, nothing contained in either the questions or answers should be considered private, personal or confidential, and are not subject to any laws concerning privacy.

Yale School of Medicine is a world-renowned center for biomedical research, education and advanced health care. Yale Medical Group (the physicians who teach, research and practice at Yale School of Medicine) is one of the largest academic multispecialty group practices in the United States. Yale Cancer Center has been a National Cancer Institute-designated comprehensive cancer center for more than 35 years, and is one of only 41 such centers in the nation and the only comprehensive cancer center in Southern New England.

Obsessive-compulsive disorder, or OCD, is a condition that affects about 2.5% of the population at some point in their lives. Obsessions are intrusive thoughts that people experience as coming from inside the mind or brain but as being somehow different from normal thoughts – more urgent, difficult-to-control, and repetitive. They are accompanied by anxiety or distress, and people typically make substantial efforts to control, neutralize, or suppress them. Compulsions are repetitive behaviors that people perform, often in a ritual-like way, to reduce the anxiety caused by the obsessions.

There are several types of OCD symptoms; two individuals with OCD can look quite different from one another. The most common groups of symptoms are anxiety about dirt or germs, accompanied by excessive cleaning; fears of violence or harm, associated with compulsive double-checking or with superstitious rituals; and discomfort with things being disordered or asymmetrical, accompanied by compulsive sorting, ordering, and arranging.

There are a number of other conditions that are thought of as being related to OCD but as importantly distinct. These include compulsive hoarding; compulsive skin-picking and hair-pulling; repetitive patterns of movement such as are seen in tic disorders; and irrational concerns with particular aspects of one’s appearance, which are seen in a condition known as body dysmorphic disorder.

What causes OCD?

The short answer is that, as is the case for almost all psychiatric disesaes, we don’t yet know what causes OCD. It is likely to be a complex interaction between genes, other biological factors, life history, and particular stresses.

It is clear that OCD can run in families. Researchers are actively searching genetic variations that may help explain why one person gets OCD and another does not. Genes are not the whole story, though: even identical twins, who have identical genetic material, can differ, with one having OCD and the other not. The best current estimate is that about 40% of the risk for OCD comes from the genes.

Environmental causes of OCD have been difficult to pin down. Stressful life events can cause symptoms to appear or to worsen; in some cases it may be that they actually cause OCD in a susceptible person, but it is more likely in most cases that they trigger or worsen a condition that was already there. Hormonal fluctuations may also influence OCD. The illness commonly starts during adolescence, and some women report symptoms worsening with their menstrual cycle or around the time of pregnancy. Some cases, especially among children, may be related to an autoimmune reaction to infection. However, this appears to be rare. The precise mechanism whereby an immune reaction may lead to OCD symptoms has been difficult to pin down, and a connection remains difficult to establish in most individual cases.

What’s the difference between being “neat/tidy” or a “germaphobe” and having OCD?

OCD can appear in different ways; indeed, two people can both have clear cases of the disorder but show totally different symptoms.

Most manifestations of OCD are really exaggerations of what would, in moderation, be normal and even helpful patterns of behavior. For example, a concern with germs and dirt, and a pattern of keeping this clean, is clearly a good thing in many contexts, such as the hospital, and was still more important in past centuries before the development of effective sewer systems and of antibiotics. It is only when such concerns get out of control and start to interfere with normal life that they are indicative of a disorder.

The official guideline for diagnosis is that the distressing thoughts and behaviors must occupy at least one hour a day and must cause significant problems with social or work functioning. The key is that it is only meaningful to call a pattern of behavior a ‘disorder’ if it leads to some significant degree of distress or problems with other aspects of life, such as relationships or work. If an individual just likes things neat and is comfortable with that, then that is best understood as a part of their personality, and not as OCD.

The term “OCD” has become a part of the common language to describe people with patterns of behavior such as in these examples. You’ve probably heard this before: “I’m so OCD about _________.” From a psychiatrist’s or psychologist’s perspective, this is a misuse of the term. Liking things a certain way is not necessarily OCD, even in cases where it causes friction with others, if it does not cause repetitive behaviors and a significant amount of anxiety or distress.

When things go wrong in pregnancy, they can quickly spiral out of control. The federal Centers for Disease Control and Prevention (CDC) recently reported a steep rise in childbirth complications, which affect about 52,000 women per year. During delivery, incidents of cardiac arrest, respiratory distress and kidney failure increased by 75% from 1999 through 2009, according to the new study by the CDC . After delivery, serious complications more than doubled over that same time period. The increase is linked to mothers who are older, obese or have conditions such as diabetes and kidney disease. Ask Yale Medicine turns to Yale Ob/Gyn physician Dr. Sonya S. Abdel-Razeq to answer the following questions on how to reduce the risks of complications during and after childbirth:

AYM: Should women having a normal pregnancy be concerned about this new finding?

Dr. Abdel-Razeq: In general, women who are healthy prior to pregnancy and have not developed any medical issues during pregnancy should not be overly concerned about these findings. The vast majority of women experience pregnancy without unexpected difficulties.

AYM: Can complications arise in pregnant women who don’t have these risk factors?

Dr. Abdel-Razeq: Unfortunately, complications may arise in any pregnant woman; however, this study has shown us that women with preexisting conditions (specifically, morbid obesity, cardiac disease, hypertension, and diabetes) are the groups of women who are overwhelmingly more likely to experience pregnancy complications.

AYM: So many things can go wrong during and after delivery, what are the highest risks?

Dr. Abdel-Razeq: Venous thromboembolic disease (including pulmonary embolism and deep venous thrombosis or DVT) is the most common cause of maternal mortality in the United States and the second most common cause of maternal mortality worldwide. Hemorrhage is the second most common complication in the United States and the most common complication occurring worldwide. Hypertensive disorders unique to pregnancy, specifically preeclampsia and gestational hypertension, are the next most common complications.

AYM: How can women prepare during pregnancy to increase their chances of having a complication-free delivery?

Dr. Abdel-Razeq: Women should aim to be as healthy as possible before pregnancy. They should see their doctor(s) regularly both before and during pregnancy and openly discuss ways to become healthier. Optimizing preexisting conditions- losing weight if obese, controlling high blood pressure and diabetes, for example- is one of the most important things a woman can do for herself. Following a good diet and also exercising at least three times per week are measures that will lend toward not only a healthy pregnancy, but also a healthy non-pregnant life!

AYM: What can hospitals and physicians do to prevent complications from occurring?

Dr. Abdel-Razeq: Hospitals and physicians play an important role in complication prevention. Staying abreast of, and following guidelines established by the American Congress of Obstetricians and Gynecologists (ACOG) for the care of pregnant women is vital. Additionally, discussing health concerns with their patients, encouraging regular visits and obtaining consultation with physicians specializing in complications of pregnancy, Maternal-Fetal Medicine physicians are also good ways to ensure the safest and best care for pregnant women.

Many people who saw the article in the New Haven Register (see link below) had been noticing increased breathing problems in themselves and their families. To answer “why,” we turned to Geoffrey Chupp, M.D., Director of the Yale Center for Asthma and Airways Disease and Associate Professor of Pulmonary Medicine at Yale School of Medicine. Dr. Chupp writes:

“The reason for the rising incidence of asthma in New Haven, across the United States and worldwide has puzzled asthma physicians and scientists since it was first recognized three decades ago.

“Numerous theories have been proposed, including genetic drift and an increase in mutations in the human genome that contribute to asthma; changes in air quality and exposure to substances (inside and outside of the home) that contribute to inflammation in the airway; and changes in human behavior (changes in hygiene and diet) that reduce the immune system’s ability to remain ‘tolerant’ to common allergens such as dust and molds or create a ‘pro-inflammatory’ environment in the airways.

“It is likely that all of these factors are contributing to the increase in asthma in New Haven, especially shifts in the environment, given the Elm City’s proximity to interstate highways and exposure to eastward-moving weather systems from cities toward the west.”

Ask Yale Medicine: Please describe the condition Hyperemesis Gravidarum. What is it, and why would a pregnant woman wind up in the hospital?

Dr. Pettker: Nausea and vomiting are common early symptoms of pregnancy. The most serious cases fall under the diagnosis of hyperemesis gravidarum (HG), which typically presents as nausea and vomiting leading to dehydration, weight loss, decreased nutrition, and abnormal salt (electrolyte) balance. It is very rare that it becomes serious enough to need hospitalization, but this sometimes is necessary if the woman needs an IV for hydration, medications, or nutrition.

AYM: What might cause it?

Dr. Pettker: We don’t know the exact cause of HG, but there is probably some influence of hormones related to pregnancy (estrogen and human chorionic gonadotropin). These are normal hormones of pregnancy which can be elevated in the first trimester. We do know that certain pregnancy conditions, such as twins and triplets, make a woman more at risk for severe nausea and vomiting.

AYM: What percentage of pregnant women suffer from it?

Dr. Pettker: About 75% of pregnant women will experience some form of nausea or vomiting during pregnancy. HG occurs in about 1-2% of pregnancies.

AYM: How long into the pregnancy does it last?

Dr. Pettker: Nausea and vomiting typically is limited to the first trimester (up to 14 weeks). Sometimes it can last through 20 weeks, in severe cases.

AYM: What is the treatment?

Dr. Pettker: The first steps are to change some behaviors. Eating more frequent meals of smaller portions seems to work. We also often recommend bland food with a high-protein content. First-line treatments proven in clinical trials include vitamin B6 and ginger (teas, capsules, or candies). Devices that provide pressure at the P6 pressure point on the inside of the wrist may help. There are also many different prescription medications available. Usually we prescribe these to be taken by mouth, but some medications can be used as suppositories for patients who are not able even to swallow pills. When these medications don’t work, we use intravenous medications, often supplementing this with intravenous hydration.

AYM: Can it be harmful to the mother or fetus?

Dr. Pettker: Rarely do the mothers suffer enough to become seriously ill. Supplemental feeding, through a feeding tube or through a bloodstream catheter, is hardly ever necessary. There is conflicting evidence if there is any significant effect on the fetus; there may be a higher incidence of low birth weight in mothers with severe HG. What seems to be clear in the medical literature is that women with HG have a lower risk for miscarriage, a reassuring point that we make sure to emphasize to patients.

AYM: Is there any way to prevent it?

Dr. Pettker: Taking a multivitamin before and at the beginning of the pregnancy appears to be a good prevention for women who have had a history of nausea and vomiting or hyperemesis.

Once again we turn to Anees Chagpar, M.D., Director of the Breast Center at Yale Cancer Center. She writes:

“Mammograms may miss up to 15% of small breast cancer, particularly in women who have very dense breast tissue. Dense breast tissue on mammography appears white, as do breast cancers, and therefore the sensitivity of mammograms to find a cancer in dense tissue is lowered.

“Screening ultrasound as an adjunct to mammography may therefore be beneficial in finding cancers that mammography may miss in women with very dense breast tissue — but it’s important to note that ultrasound is not an appropriate screening test on its own.”

October is national Breast Health Awareness Month, which makes this question very timely. To answer it, we turned to Yale Cancer Center breast surgeon Anees Chagpar, M.D., director of the Breast Center at Smilow Cancer Hospital at Yale-New Haven. She writes:

“There has been a lot of debate about the value of self-breast exams in detecting breast cancer. While the evidence has been varied regarding the importance of self-breast exams in finding cancer early, many still recommend self-breast exams for women to become familiar with their own bodies, so they can detect lumps that may be different from their usual breast texture.

“In addition, particularly for women who are younger than age 40 (when routine annual mammography generally starts), self-breast exams can help women to find new breast lumps, skin changes, or nipple discharge that may be the first signs of breast cancer.

“Some women, however, feel uncomfortable doing monthly self-breast exams or may be anxious when finding ‘lumpy bumpy breast tissue’ that may be completely normal. Your doctor can help by doing yearly clinical breast exams and recommending that women get regular mammograms beginning at age 40.”

Our answer comes from Peter Schulam, M.D., chairman of the department of urology at Yale School of Medicine, and head of the prostate and urologic cancers program at Yale Cancer Center. He writes:

“An enlarged prostate does not put you at an increased risk for prostate cancer. Benign prostatic hypertrophy (BPH), however, can result in an elevated PSA and anyone with an elevated PSA should be evaluated by a physician to rule out prostate cancer.”

For an answer, we turned to Tom Lynch, M.D., director of Yale Cancer Center and physician-in-chief of Smilow Cancer Hospital at Yale-New Haven. Dr. Lynch is a world-renowned expert in lung cancer and the development of novel therapies. He writes:

“The good news is that your risk of cardiovascular (heart and vessels) disease decreases to that of a non-smoker about a year after quitting. Your risk of lung cancer takes longer to reach that of a non-smoker (25-30 years), and depends upon the age of the patient and the amount of cigarettes smoked. Finally, the good news is that further damage to the lungs that can lead to emphysema and bronchitis stops as soon as you stop smoking.”

“There are three categories of allergy pills; antihistamines, decongestants, and leukotriene inhibitors. They all work fairly rapidly. I don’t continue the first two for more than a week if they’re not working. Leukotriene inhibitors (i.e. Singulair) may have a more cumulative effect, especially in children who have large tonsils and adenoids.”

We turned to Peter Whang, M.D., spine expert at the Yale School of Medicine Department of Orthopaedics. He writes:

“Low back pain is, unfortunately, a ubiquitous problem in our society. Approximately 80% of individuals will have an episode of low back pain at some point in their lives and it is one of the most common reasons for doctor visits.

“Low back pain can be caused by numerous conditions such as arthritis affecting the discs or joints of the spine, or muscle strains. On rare occasions, more serious disorders can also result in back pain, including fractures, tumors, infections, or even pathology in the abdomen or pelvis. Depending upon which anatomic structures are involved, this pain can radiate to other parts of the body like the buttocks or hips. Specifically, if there is any irritation of the nerves of the spine, a patient can even experience symptoms radiating into one or both legs.

“Because there are so many potential causes, low back pain can be very challenging to treat. Nevertheless, the majority of individuals may be managed effectively with conservative measures consisting of activity modification, physical therapy, and anti-inflammatories or other medications.

“In some instances, it may be beneficial to consider spinal injections, which are intended to decrease inflammation and hopefully provide symptomatic relief. Surgery may be a reasonable option for patients with chronic low back pain that has proven to be resistant to these other types of treatments, or for cases in which there is significant nerve compression (i.e. pain, numbness, or weakness in the legs).

“In the past we often performed fusions for this problem, but in recent years, newer operative strategies have been developed, including minimally invasive and motion-preserving techniques. Unfortunately, recurrent low back pain is not uncommon so if these symptoms do not resolve over time, it may be worthwhile to see your physician for further evaluation.”